Like an elastic ball

The great French surgeon Guillaume Dupuytren was known to his unfortunate juniors as ‘the Napoleon of surgery’ and ‘the brigand of the Hôtel Dieu’, the Paris hospital where he reigned supreme. While he was a difficult character, he was also very good. His name is mainly associated today with Dupuytren’s Contracture, a condition which causes the fingers to curve into the palm of the hand. But he was one of the most celebrated clinicians of the early 19th century, making contributions in more or less every field of surgery. His work in the management of burns, orthopaedics, the surgery of aneurysms and colorectal conditions was all of great significance. For a more detailed summary of his achievements you’ll find an excellent article here.

Here’s a Duyputren surgical tour de force, reported in The Medical Recorder in 1825.

The patient Madame Thiebault, 21 years of age, was a favourite of the Duchess of Berry, and about two years previously perceived a small tumour on the top of the right shoulder, which enlarged to such a size, that M. Boyer was consulted. He advised that no operation should be performed, and prognosticated that the removal of the tumour would be fatal. This advice not being relished, M. Dupuytren was called in. He found an enormous tumour occupying the posterior and lateral part of the neck, on the right side, extending from the mastoid process to the inferior angle of the scapula.

In other words, from the base of the skull, just behind the ear, to the shoulder blade.

The tumour was hard and unequal on its surface. It was every where firmly adherent to the neighbouring parts. The skin covering it was tense, and full of dilated veins.

A significant observation, since (particularly at this date) a tumour with an extensive network of blood vessels would be more difficult to remove.

The patient experienced sharp pains in the tumour, and was unable to use the right arm, in which there was a sense of unpleasant formication.

‘Formication’ is a lovely medical word describing the sensation of small insects crawling on the skin. It comes from the Latin formica, meaning ‘ant’.

Dupuytren agreed to go ahead with the operation, which took place on 27th September 1822. All that followed took place without the benefit of anaesthetic.

Dupuytren made an incision, ten or twelve inches in extent, over the greatest diameter of the tumour—that was, from the top of the cervical column to the acromion scapulae.

From the top of the neck to the edge of the shoulder blade where it meets the collar bone.

The trapezius muscle being thus exposed, was divided, and the tumour itself came in view. By a long, painful, and we need hardly say, dexterous dissection, during which many arteries were cut and tied, this enormous tumour was turned out by main force and free incisions. It fell on the ground and bounded like an elastic ball.

I must admit that I wish I’d seen that.

Several arteries, which gave out blood freely, were secured, and the immense wound was dressed. The intrepid lady never complained during this terrific dissection, but talked calmly to the surgeon all the time.

I can imagine being able to chat to the surgeon if local anaesthetic were involved – but under these circumstances? I take my hat off to her.

In the night of the same day the lady was seized with pain in the throat, with difficulty of swallowing; but these symptoms were removed by a moderate bleeding. A kindly suppuration became established—granulations shot forth—the limits of the wound decreased—and the lady got perfectly well, and has remained so.

She was certainly lucky: in the absence of antiseptic measures there was a very high probability of postoperative infection. But she was doubly lucky to have one of France’s greatest surgeons looking after her. Dissecting the tumour free of surrounding tissue was no easy task. One of the challenges of surgery has always been effective haemostasis – arresting the bleeding which occurs when a blood vessel is cut through. Dupuytren displayed technical assurance which I’m sure many modern surgeons would admire.

The tumour weighed six French pounds—was of a fibro-cellular texture—and contained some intermixed portions of albuminous lymph. In some points, the tumour appeared to be taking on the carcinomatous character.

Becoming malignant, in other words. Six ‘French pounds’ is 3 kilograms or 6 lb 10 oz. Huge, by any measure.

The event falsified the prognosis of M. Boyer; but, probably, there were few other surgeons than M. Dupuytren, who would have undertaken so terrible an operation.